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E5103 Registration Worksheet (step 1) Doxorubicin, Cyclophosphamide, and Paclitaxel With or Without Bevacizumab in Treating Patients With Lymph Node-Positive or High-Risk, Lymph Node-Negative Breast Cancer Source Form: NCI FormBuilder: https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=4C7BBF65-46E3-4B47-E044-0003BA3F9857

Link:

https://formbuilder.nci.nih.gov/FormBuilder/formDetailsAction.do?method=getFormDetails&formIdSeq=4C7BBF65-46E3-4B47-E044-0003BA3F9857

Keywords:

Clinical Trial

Eligibility Determination

Breast Neoplasms

Versions (3)

8/26/12 8/26/12 -
1/9/15 1/9/15 - Martin Dugas
9/17/21 9/17/21 -

Uploaded on:

September 17, 2021

DOI:

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License :

Creative Commons BY-NC 3.0 Legacy

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Breast Cancer NCT00433511 Eligibility - E5103 Registration Worksheet (step 1) - 2746547v1.0

English 1

English

Details

No Instruction available.

1 forms

StudyEvent: E5103 Registration Worksheet (step 1)
1. No Instruction available.

Eligibility

First initial

Last initial

Has the eligibility checklist been completed

Yes

In the opinion of the investigator, is the patient eligible?

Yes

Has written informed consent been obtained

Yes

Date Informed Consent Signed

Has HIPAA authorization been obtained

Exempt - Non-usa Participant (Exempt - non-USA participant)

No: C49487 (No)

Yes: C49488 (Yes)

HIPAA Authorization Date

Is the tumor ER positive

Yes

Lymph Node Involvement

1-3 (1-3)

>=4 (>=4)

Negative (negative)

Type of surgery and planned radiotherapy

Breast Conserving Surgery Plus Whole Breast Radiation Therapy (Breast conserving surgery (WBRT))

Breast Conserving Surgery Plus Accelerated, Partial Breast Irradiation Before And/or After Chemotherapy (Breast conserving surgery (APBI pre/post chemo))

Mastectomy With Either Local Or Regional Rt (Mastectomy with either local or regional RT)

Mastectomy Without Rt (Mastectomy without RT)

AC shedule planned

Standard Chemotherapy Regimen Delivered Every 3 Weeks (Classical - every 3 weeks)

Dose Dense Chemotherapy Regimen Administered Every 2 Weeks (Dose dense - every 2 weeks)

Principal Investigator

Phone

Fax Number

Email address

Senior Clinical Research Associate/Data Manager

Phone

Fax Number

Email address

Patient Weight (kg)

Patient weight (lb)

Do you wish to use an express carrier to ship the drugs (at your expense)?

No (no)

Unknown (unknown)

Yes (yes)

Name of express carrier

Airborne Express (Airborne Express)

Dhl (DHL)

Federal Express (Federal Express)

Ups (UPS)

Other (Other)

Unknown (Unknown)

Express account number

Contact person for drug ordering

Phone

E-mail address

QOL contact person

Phone

Email address

I agree to participate in the laboratory research studies that are being done as part of this clinical trial.

Yes

I agree to provide additional blood for research.

Yes

I agree to provide urine for research.

Yes

My specimens may be kept for use in research to learn about, prevent, treat, or cure cancer.

Yes

My specimens may be kept for research about other health problems (for example: causes of diabetes, Alzheimer's disease, and heart disease)

Yes

Someone from this institution may contact me in the future to ask me to take part in more research.

Yes

Name of the contact person responsible for sample submission

Phone number of the contact person responsible for sample submission

Fax number of the contact person responsible for sample submission

E-mail address of the contact person responsible for sample submission

Patient Demographics / Pre-treatment Characteristics

Patient's Sex

Female (F)

Male (M)

Birthdate (mm/yy)

Patient Race (check all that applyU.S. and Canada only)

A Person Having Origins In Any Of The Original Peoples Of Europe, The Middle East, Or North Africa. (White)

A Person Having Origins In Any Of The Black Racial Groups Of Africa. Terms Such As "haitian" Or "negro" Can Be Used In Addition To "black Or African American." (Black or African American)

A Person Having Origins In Any Of The Original Peoples Of The Far East, Southeast Asia, Or The Indian Subcontinent Including, For Example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, The Philippine Islands, Thailand, And Vietnam. (Asian)

Not Provided Or Available (Not Reported)

3 more items in the detailed view.

ZIP Code

Patient Ethnicity

A Person Of Mexican, Puerto Rican, Cuban, Central Or South American Or Other Spanish Culture Or Origin, Regardless Of Race. (Hispanic or Latino)

A Person Not Meeting The Definition For Hispanic Or Latino. (Not Hispanic or Latino)

Not Provided Or Available (Not reported)

Could Not Be Determined Or Unsure (Unknown)

Patient Hospital No.

Patient Social Security Number

Method of payment (check one)

Medicaid (Medicaid)

Medicaid And Medicare (Medicaid and Medicare)

Medicare (Medicare)

Medicare And Private Insurance (Medicare and Private Insurance)

9 more items in the detailed view.

Attending Physician

Institution contact

Registrar

Country of Residence

Comments

Signature of treating physician (I have reviewed the above data and agree the date are accurate and correct)

Date (Note: Date must be on or before date of registration)

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Breast Cancer NCT00433511 Eligibility - E5103 Registration Worksheet (step 1) - 2746547v1.0

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